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STATE OF CALIFOPGIA WATER RESOURCES COOL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATIONQp COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑G RENEWAL PERMIT' [:]5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 6119 FACILITY/SITE NAME WHERE TANK IS INSTALLED: J?UY/ i(/ , "51L rz c i« FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A OWNERS TANK ID/ / S. MANUFACTURED BY: L( C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK C ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A I MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED DIESEL S CHEMICAL PRODUCT 1 OIL 1 PRODUCT ❑ A GASAHOL 5 JET NEL 8 AVIATION GAS 5 HAZARDOUS 80 EMPTY [:]95 UNKNOWN 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED S C.A.S.I C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,L D A TYPE OF ❑ I AUED 0 SINGLE WALLED WITH EXTERIOR U ER ❑ 95 mmm SYSTEM 2 SI WALLED 1 SECONDARY CONTAINMENT ❑99 OTHER STEELINN ❑2 STAINLESS STEEL ❑7 FIBERGLASS ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ e POLYW mCLCRDE ❑ 7 ALuMINUM ❑8 IW%METHANOLCOMPATIBIEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑2 NG ❑2 EPDXY UNING ❑ 1 PHENOLIC LINING LINING ❑5 GLASS UNING NED ❑95 UM(NOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METNN401.7 ❑YES ❑NO ❑99 OTHER rPCROOFITE, SION ❑ I POLYETHIFNEWRAP ❑2 ORASPHALT ❑0 WNYL WRAP ❑ 1 FIBERGLASS REINFORCED PIASTIC CTION ❑5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNO, U IFUNOERGROUND,SOTH IFAPPLICABLE A.SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 9 GRAVITY A U 91 NONE A U 9 KN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WAILED A U 9 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER I STEEL A U 2 STAINLESS HEEL A U 9 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A ALUMINUM A U 8 CONCRETE A U I STEEL CLAD W/FRP A U 6 1909A METHANOL COMPATIBLE FRP A U 9 LIALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P B 1VISUAL CHECK P B 2 INVENTORY RECONCILIATION P 6 9VADOSE WELLS P 6 A ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P 6. p PRECISION TESTING P 6 7 PRESSURE TESTING P 6 91 NONE P 6 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF �,WAS TANK FILLED WITH \ SUBSTANCE REMAINING IN <0 l GALLONS INERT MATERIAL? ❑YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED p SIGNAL URE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION I AGENCY I FACILITY ID I TANK ID I CURRENT LOCAL AGENCY FACILITY ID/ APPROVED BY NAME PHONE I WITH AREA CODE C L/--�'C'k / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE V \ CHECK( PERMITAMOUNT URCHARGE AMT. FEECODE CEIPTI pY; _ J V Innu nln.94.AAi THIS FORM YIIRT BC/CPOupIYlCA RV A CAM( 0 u .A. uw e.. ....,.,..... ..........